Regular Article

Evaluating the efficacy of scalp cooling using the Penguin cold cap system to reduce alopecia in patients undergoing chemotherapy for breast cancer

Chemotherapy-induced alopecia is a common and distressful side effect, especially among breast cancer patients. Scalp cooling (SC) can reduce hair loss during anthracycline- and taxane-based chemotherapy. This study assessed the effectiveness of SC in daily clinical practice in three Italian oncology units.

From 2014 to 2016, we prospectively included 220 female early-stage breast cancer patients undergoing curative chemotherapy in combination with SC using the Paxman device. Effectiveness was defined as the severity of hair loss according to the Common Terminology Criteria for Adverse Events Version 4.0 as follows: Grade 0, no hair loss; Grade 1, <50% hair loss not requiring a wig; and Grade 2, ≥50% hair loss at each cycle and at completion of chemotherapy. The tolerability and safety were also evaluated.

The overall success rate of SC (hair loss Grade 0–1) was 68%. Severe hair loss was avoided in 89% of women receiving taxane-based chemotherapy and in 78% of women receiving both anthracyclines and taxanes. Among women undergoing anthracycline-based chemotherapy, 47% experienced hair preservation. SC was well tolerated, as only 20 patients discontinued SC for reasons other than hair loss.

Our study confirmed that SC provides a reliable chance for breast cancer patients to keep their hair during taxane- and/or anthracycline-based chemotherapy.

Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

Alopecia is one of the most distressing side effects of chemotherapy. Evaluating and comparing the efficacy of potential therapies to prevent chemotherapy-induced alopecia (CIA) has been complicated by the lack of a standardized measurement for hair loss. In this study we investigated the correlation between patient-reported outcome assessments and quantitative measurement with the hair check to assess CIA in clinical practice.

Scalp cooling efficacy was evaluated by patients by World Health Organisation (WHO) of CIA, Visual Analogue Scale (VAS) and wig use. The Hair Check was used to determine the amount of hair (in mm²) per unit of scalp skin area (in cm²) (Hair Mass Index, HMI). CIA was also evaluated by doctors, nurses and hairdressers.

Baseline HMI was not predictive for hair loss. HMI declined throughout all chemotherapy cycles, which was not reflected by patient-reported measures. HMI correlated with patient-reported hair quantity before the start of the therapy, but not with WHO and/or VAS during therapy. Patient's opinion correlated moderately with the opinion of doctors and nurses (ρ = 0.50–0.56 respectively), but strongly with hair dressers (ρ = 0.70).

The Hair check is suitable to quantify the amount of hair loss and could complement research on refining outcome of scalp cooling, but the patient's opinion should be considered as the best method to assess hair loss in clinical practice.

Trialregister.nl NTR number 3082.

Conventional chemotherapy leads to multiple adverse mucocutaneous complications such as oral mucositis, alopecia, ocular toxicity, and onycholysis. Limited pharmacologic interventions are available for preventing these clinical problems.

This study aimed to critically review the role of cryotherapy (regional hypothermia) for alleviating these adverse symptoms.

A narrative review was performed, with an emphasis on randomized controlled trials. A comprehensive search using PubMed, Ovid, Embase, and MEDLINE^® was completed. References of all cited articles also were reviewed. Data from the review were composed of articles published between 1970 and May 2013.

Available evidence suggests that regional hypothermia decreases the burden of chemotherapy-related oral mucositis, alopecia, ocular toxicity, and onycholysis. The major limitations of studies include the absence of blinded control groups and variable clinical end points.

Regional hypothermia decreases the burden of these four chemotherapy-induced complications and is well tolerated. More research is needed to determine what subgroups of cancer patients are most likely to respond to different types of regional hypothermia, the ideal duration of cooling needed, and further improve the ease of use of the cooling devices.

Les principaux objectifs de cette revue de la littérature sont de déterminer si la technologie du casque réfrigérant est efficace et sécuritaire, s’il existe des effets secondaires et si la qualité de vie des patients est améliorée. En termes d’efficacité, le casque réfrigérant semble obtenir de bonnes performances dans son objectif de prévenir la chute des cheveux chez des patients en traitement de chimiothérapie. La moyenne pondérée des résultats de toutes les études répertoriées indique ainsi que cette technologie permet à 63,5 % des patients d’avoir une bonne conservation de leurs cheveux. Dans les études disposant d’un groupe de contrôle, les taux pondérés de bonne conservation des cheveux sont de 50,6 % avec casque réfrigérant et de 16,3 % sans. Du point de vue de la sécurité de la technologie, le risque principal est celui de permettre à des métastases de pouvoir se développer au niveau du cuir chevelu. Toutefois, aucune étude n’a réussi à démontrer une différence statistiquement significative entre des groupes de patients ayant bénéficiés d’une chimiothérapie avec ou sans casque réfrigérant.

The main objectives of this literature review are to determine if scalp cooling is efficient and safe, if there are side effects and if the patients’ quality of life improves. In terms of effectiveness, scalp cooling seems to get good performance in its aim to prevent hair loss in patients receiving chemotherapy. The weighted average results of all identified studies indicate that this technology allows for 63.5% of patients to have a good preservation of their hair. In studies with a group of control, the weighted rates of good preservation of the hair are 50.6% with scalp cooling and 16.3% without. From the standpoint of safety technology, the main risk is that of scalp metastases. However, no study has successfully demonstrated a statistically significant difference between groups of patients receiving chemotherapy with or without scalp cooling.

Chemotherapy-induced alopecia causes an important impact on cancer patients and its risk of persistence is currently a considerable issue in cancer survivors. Of the various interventions proposed for the prevention of chemotherapy-induced alopecia, scalp cooling has emerged as an effective and safe strategy. This paper aims to provide an overview on scalp cooling and chemotherapy-induced alopecia prevention.